Preeclamptic heart failure - perioperative concerns and management: a narrative review.

Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.

Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial.

OBJECTIVE: To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. METHODS: In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). RESULTS: We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. CONCLUSION: Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

Anaesthetic concerns of a child with symptomatic vitamin D deficiency rickets with secondary hyperparathyroidism: A case report.

Rickets is a paediatric bone disorder characterised by defective mineralisation of bony matrix due to abnormalities in calcium and phosphate metabolism. Despite being a common disease globally, literature on the anaesthetic concerns in rickets are scant. Herein, we describe the management of a 12-year-old child with symptomatic vitamin D deficiency rickets with secondary hyperparathyroidism, undergoing general anaesthesia for an urgent orthopaedic procedure. There are numerous risks involved in such a case, such as hypocalcemia, hypophosphatemia, chest and vertebral deformities, restrictive lung disease, difficult intubation and weaning, difficult regional anaesthesia, chronic bone pain, infectious complications and postoperative decreased renal function, all of which require careful preoperative assessment and risk stratification. In elective surgeries, it is important to optimise the metabolic parameters before taking up the case. However, in urgent and emergent procedures like ours, it is imperative to take up the case after informing the parents of the risks involved.

Perioperative concerns in a patient with suspected Creutzfeldt - Jakob disease: A case report and review of literature.

A case of Creutzfeldt-Jakob Disease (CJD), a rare prion disease, posted for surgery is a clinically challenging scenario for an anesthesiologist. In addition to weighing in the consequences of using general versus neuraxial anesthesia for a patient of such a progressive neurodegenerative disorder, the anesthesiologist must also meticulously plan and institute a robust infection control protocol, keeping in mind that prion diseases are transmissible and highly resistant to the standard sterilization process. We hereby report the successful anesthetic management of a 57-year-old patient with suspected CJD presented with intertrochanteric fracture femur for closed reduction and internal fixation and also review the existing literature regarding the anesthetic management of a definite or suspected case of CJD.

Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial / Eficácia da melatonina na redução da incidência de delirium em pacientes adultos graves: um ensaio clínico randomizado

ABSTRACT Objective: To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. Methods: In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). Results: We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. Conclusion: Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

RESUMO Objetivo: Determinar se a melatonina enteral diminui a incidência de delirium em adultos em estado grave. Métodos: Neste estudo controlado e randomizado, os adultos foram admitidos à unidade de terapia intensiva e/ou receberam apenas o padrão de cuidado habitual (Grupo Controle) ou o tratamento combinado com 3mg de melatonina enteral uma vez ao dia às 21h (Grupo Melatonina). A ocultação da alocação foi feita por meio de envelopes selados opacos e numerados sequencialmente. O intensivista que avaliou o delirium e o pesquisador que realizou a análise dos dados foram cegados quanto à alocação do grupo. O desfecho primário foi a incidência de delirium dentro de 24 horas de internação na unidade de terapia intensiva. Os desfechos secundários foram a incidência de delirium nos dias 3 e 7, a mortalidade na unidade de terapia intensiva, a duração da internação na unidade de terapia intensiva, a duração da ventilação mecânica e o escore da escala de desfecho de Glasgow (na alta). Resultados: Foram incluídos 108 pacientes na análise final, com 54 sujeitos em cada grupo. Em 24 horas de internação na unidade de terapia intensiva, a incidência de delirium não foi diferente entre os Grupos Melatonina e Controle (29,6% versus 46,2%; RR = 0,6; IC95% 0,38 - 1,05; p = 0,11). Nenhum desfecho secundário apresentou diferenças estatisticamente significativas. Conclusão: Em adultos em estado grave, 3mg de melatonina enteral não foi mais eficaz que os cuidados padrão na redução da incidência de delirium.

Postoperative outcome of neonatal emergency surgeries in a tertiary care institute-A prospective observational study.

AIMS: Neonatal surgical mortality continues to be high in developing countries. A better understanding of perioperative events and optimization of causative factors can help in achieving a favorable outcome. The present study was designed to evaluate the perioperative course of surgical neonates and find out potential factors contributing to postoperative mortality. METHODS: This prospective observational study enrolled neonates, undergoing emergency surgical procedures in a tertiary care institute. Primary outcome was 6 weeks postsurgical mortality. The babies were observed till discharge and subsequently followed up telephonically for 6 weeks after surgery. Multivariable logistic regression analysis of various parameters was performed. RESULTS: Out of the 324 neonates who met inclusion criteria, 278 could be enrolled. The median age was 4 days. Sixty-two (27.7%) neonates were born before 37 weeks period of gestation (POG), and 94 (41.8%) neonates weighed below 2.5 kg. The most common diagnoses was trachea-esophageal fistula (29.9%) and anorectal malformation (14.3%). The median duration of hospital stay for survivors was 14 days. The in-hospital mortality was 34.8%. Mortality at 6 weeks following surgery was 36.2%. Five independent risk factors identified were POG < 34 weeks, preoperative oxygen therapy, postoperative inotropic support postoperative mechanical ventilation, and postoperative leukopenia. In neonates where invasive ventilation was followed by non-invasive positive pressure ventilation in the postoperative period, risk of postoperative surgical mortality was significantly reduced. CONCLUSION: Present study identified preterm birth, preoperative oxygen therapy, postoperative positive pressure ventilation, requirement of inotropes, and postoperative leukopenia as independent predictors of 6-week mortality. The possibility of early switch to noninvasive positive pressure ventilation was associated with a reduction in neonatal mortality.

Harmonizing the Septic Shock Terminology: Need of the Hour.

How to cite this article: Magoon R, Puri S, Bandyopadhyay A. Harmonizing the Septic Shock Terminology: Need of the Hour. Indian J Crit Care Med 2023;27(4):294-295.

Supraglottic airway device versus tracheal tube for pediatric laparoscopic surgery-A systematic review and meta-analysis.

BACKGROUND: Conventionally, tracheal tubes have been used for general anesthesia in pediatric laparoscopic surgeries. Recently, supraglottic devices are being used for the same. The performance of supraglottic devices versus tracheal tubes in children undergoing laparoscopic surgery is uncertain. METHODS: A systematic review and meta-analysis of randomized controlled trials that compared supraglottic devices versus tracheal tubes in patients ≤18 years undergoing laparoscopic surgery under general anesthesia was conducted. The outcomes were peak airway pressures (cm H2 O), end-tidal carbon dioxide during pneumoperitoneum (mm Hg), recovery time (min), postoperative sore throat and adverse events. Mean difference and odds ratio, with 95% confidence intervals were reported using a random effect model. RESULTS: Eight trials (n = 591) were included in the final meta-analysis. There was no statistically significant difference in the peak airway pressures (MD 0.58, 95% CI: -0.65 to 1.8; p = .36) and end-tidal carbon dioxide (MD -0.60, 95% CI: -2.00 to 0.80; p = .40) during pneumoperitoneum in the supraglottic device and the tracheal tube group. The tracheal tube group had higher odds of sore throat (OR 3.30, 95% CI: 1.69-6.45; p = .0005) and the supraglottic airway group had faster recovery time (MD 4.21, 95% CI: 3.12-5.31; p < .0001), which were statistically significant. The certainty of evidence is graded low. CONCLUSION: There is low quality evidence to suggest that for pediatric laparoscopic surgeries of short duration, supraglottic devices could provide comparable intraoperative ventilation in terms of peak airway pressures and end tidal carbon dioxide, with lower odds of postoperative sore throat and faster recovery time when compared to tracheal tubes.

Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial.

BACKGROUND: Critically injured patients who are agitated and delirious on arrival do not allow optimal preoxygenation in the emergency area. We investigated whether the administration of intravenous (IV) ketamine 3 minutes before administration of a muscle relaxant is associated with better oxygen saturation levels while intubating these patients. METHODS: Two hundred critically injured patients who required definitive airway management on arrival were recruited. The subjects were randomized as delayed sequence intubation (group DSI) or rapid sequence intubation (group RSI). In group DSI, patients received a dissociative dose of ketamine followed by 3 minutes of preoxygenation and paralysis using IV succinylcholine for intubation. In group RSI, a 3-minute preoxygenation was performed before induction and paralysis using the same drugs, as described conventionally. The primary outcome was incidence of peri-intubation hypoxia. Secondary outcomes were first-attempt success rate, use of adjuncts, airway injuries, and hemodynamic parameters. RESULTS: Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02). A significant improvement in mean oxygen saturation levels from baseline values was seen in group DSI only. There was no incidence of hemodynamic instability. There was no statistically significant difference in airway-related adverse events. CONCLUSIONS: DSI appears promising in critically injured trauma patients who do not allow adequate preoxygenation due to agitation and delirium and require definitive airway on arrival.

Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment.

How to cite this article: Bandyopadhyay A, Puri S, Ashok V. Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment. Indian J Crit Care Med 2023;27(1):78.

Supplemental intraoperative crystalloids for pediatric postoperative nausea and vomiting-A systematic review and meta-analysis.

BACKGROUND: Postoperative nausea and/or vomiting is a relatively frequent occurrence after general anesthesia in pediatric patients. Supplemental perioperative crystalloid fluid administration has been shown to have a positive effect on the incidence of nausea and/or vomiting in adults undergoing surgery. The question arises whether supplemental intraoperative intravenous fluids in pediatric patients offers beneficial results with regards to pediatric postoperative nausea and/or vomiting. METHODS: Pubmed, EMBASE, Google Scholar, and Web of Science were searched up to March 2022 to perform a systematic review with meta-analysis of randomized controlled trials involving patients ≤18 years undergoing elective surgery under general anesthesia, with one group receiving conventional intraoperative fluids therapy and the other group receiving supplemental intraoperative fluid therapy, with intravenous crystalloids. The outcomes included incidence of postoperative vomiting, postoperative nausea and vomiting, the need for rescue anti-emetics, postoperative thirst, and adverse events attributed to supplemental intravenous fluid therapy. Relative risk (RR) with 95% confidence intervals (CIs) were reported for the outcomes using a random or fixed effects model. RESULTS: Seven randomized controlled trials (864 patients) were included in the final analysis. Supplemental intraoperative crystalloids reduce postoperative vomiting (RR 0.56, 95% CI 0.39-0.80; p = .001), postoperative nausea and vomiting (RR 0.52, 95% CI 0.37-0.74; p = .0003), postoperative thirst (RR 0.21, 95% CI 0.13,0.34; p < .01), and the need for rescue anti-emetics postoperatively (RR 0.60, 95% CI 0.49-0.74; p = .00001). CONCLUSION: Supplemental intraoperative intravenous crystalloids significantly reduce several PONV outcomes in healthy children undergoing relatively simple and superficial surgeries under volatile agent-based general anesthesia.

Colonization of the central venous catheter by Stenotrophomonas maltophilia in an ICU setting: An impending outbreak managed in time.

BACKGROUND: Stenotrophomonas maltophiliacauses opportunistic infections in immunocompromised and patients in intensive care units (ICUs). An outbreak of S. maltophilia in ICU is described which highlights the importance of the risk of infection from contaminated medical devices and suction fluids in ventilated patients. METHODS: The investigation of the outbreak was carried out. Environmental sampling was done. This was followed by MALDI-TOF MS typing and recA gene-based-phylogeny. RESULTS: In February, S. maltophilia was reported from the central line blood of six patients from ICU within a span of two weeks. The peripheral line blood cultures were sterile in all patients. Relevant environmental sampling of the high-touch surface and fluids revealed S. maltophilia strains in normal saline used for suction and in the inspiratory circuit of two patients. The isolated strains from patients and environment (inspiratory fluid) showed a minimum of 95.41% recA gene sequence identity between each other. Strict cleaning and disinfection procedures were followed. Continuous surveillance was done and no further case of S. maltophilia was detected. Timely diagnosis and removal of central line prevented development of central-line associated blood stream infection. CONCLUSION: This outbreak report illustrates that environmental sources like suction fluid and normal saline could be the source of S. maltophilia in ICU patients.